HEAD INJURIES Flashcards
TBI contributes significantly to the death of approximately ______ of all trauma victims.
half
The brain is surrounded by how much csf?
150ml
Brain tissue, blood, and CSF exert a pressure within the brain, which isreferred to as
intracranial pressure (ICP)
Hemorrhage or edema that leads to herniation of the brain will compress what CN, Leading to pupillary dilation?
Cranial nerve III (oculomotor)
What pressure is used to characterize pressure driving blood into the brain
Mean arterial pressure (MAP)
How do you calc MAP?
(systole +diastole x2/3) or diastole + 1/3 pulse pressure
What is the amount of pressure it takes to push blood through cerebral circulation. To maintain oxygen, glucose delivery
Cerebral perfusion pressure (CPP)
CPP is calculated how?
MAP-ICP
Normal CPP =
70-80mmhg
Historically _____ has been use to lower ICP
hyperventilation
What type of injury?
(a)Direct trauma to the brain
(b)Contusion, hemorrhages, lacerations or direct mechanical injury
(c) Neural tissue does not regenerate well therefore low expectation of recovery of the tissue associated
Primary brain injury
Types of secondary injury include:
1) Mass effect – elevated ICP (can lead to herniation)
2) Hypoxia (inadequate delivery of O2)
3) Hypotension
2 biggest predictors of poor outcome in head trauma are
-Amount of time spent with ICP > 20mmHg
-Time spent with systolic BP < 90mmHg
Cushing’s triad refers to
elevated systolic BP, bradycardia and
abnormal respirations (Cheyne-stokes)
Once life threatening injuries have been managed if time permits or during transport perform _____
secondary assessment
single most important observation for TBI during secondary survey
Constant/continuous observation of mental status
Depressed vs non depressed skull fractures.
______ can often be palpated and may require surgical intervention
Depressed
________ - suspect if CSF drainage or delayed (several hours) findings of periorbital ecchymosis or battle signs are seen
Basilar skull fracture
Trauma to the eye and orbit must be considered with facial trauma evaluate for:
(a) Hyphema
(b) Open globe
What type of eye injury?
signs include tear drop pupil, sub conjunctival hemorrhage, decrease in vision
Open globe
_________ is a head injury from a hit, blow, or jolt to the heat that:
(a) Briefly knock you out (loss of consciousness), OR
(b) May affect your ability to remember information before, during, or after the event (post traumatic amnesia), OR
(c) Makes you feel dazed, like you had your bell rung (alteration of consciousness)
Concussion
also known as a mild traumatic brain injury
What issue?
(a) Bleeding between skull and Dura Mater
(b) 1-2% of TBI patients
(c) Usually low velocity blow to temporal bone
(d) Pathognomonic history is patient has head trauma with a brief LOC, regains consciousness (lucid interval), then experiences rapid decline in consciousness
(e) Due to the location of the bleed the patient have a great recovery if rapid surgical intervention is performed
(f) Watch for dilated, sluggish non-reactive pupil
Epidural hematoma
What issue?
(a) Account for 30% of severe brain injuries
—1)MVC, falls
(b) Generally results from venous bleed
(c) Bridging veins are torn during blow to the head
(d) Blood collects between Dura and Arachnoid membrane
(e) Typically results from relatively rapid accumulation of blood in the subdural space and rapid onset of mass effect
Subdural hematomas
(a) Bleeding that occurs between arachnoid membrane
(b) Many vessels located in this space
(c) Commonly associated with ruptured cerebral aneurysm and onset of worst headache of life. However, post traumatic is the most common cause. Symptoms include:
-1) Severe HA
-2) Nausea & vomiting
-3) Dizziness
-4) May have meningeal signs
-5) Seizures
(d)Does not cause mass effect due to location therefore surgical intervention is not common
Subarachnoid Hemorrhage (SAH)
All penetrating brain injuries result in an open fracture with, if the patient survives they pose a high risk for ________
potential infection
Penetrating cranial injury
management
Manage airway and administer antibiotics.
Management Airway
(a) Patients with decreased LOC may be unable to protect their airway. Adequate oxygen delivery to the brain is crucial in these patients to prevent _____
(b) _______ – monitor for obstruction/clotting within these adjuncts
(c) C –Collar (may be deferred if compromises airway management – manual stabilization continued until collar placed if clinically indicated.)
(d)Definitive airway ( if GCS < ___) is ideal however supraglottic devices can serve to maintain an airway in the field setting. ALWAYS have suction equipment available.
a) secondary brain injury
b) NPA/OPA
d) 9
Management Breathing
(a) All suspected TBI should receive supplemental ____
(b) Continuous pulse oximetry monitoring. Why?
(c) Be cautious when ventilating with BVM/Ventilator and optimally control ventilator rate as alterations in _____ can aggravate TBI
(d) Judge the degree of ventilation by counting breaths per minute (____ for adults)
(e) Controlled ________ is only used in specific circumstances i.e. signs of herniation (dilated pupil, posturing or no motor response) for short periods of time
a) O2.
b) Hypoxia can worsen outcome maintain O2 > 95% optimally.
c) CO2
d) 10
e) hyperventilation
_______ are important causes of secondary brain injury
Blood loss and hypotension
After mild TBI/Concussion there is a ______ minimal recovery period
24-hour
Mild Traumatic Brain Injury
Recovery is different for each person, but symptoms typically improve within ____, and resolve completely within ________
-hours
-days to weeks
Red Flags: if any red flags are present then you need to ……
immediately refer to a higher level of care and consider urgent evacuation
What are these?
(a) Deteriorating level of consciousness
(b)Double vision
(c) Increased restlessness, combative, or agitated behavior
(d) Repeated vomiting
(e) Seizures
(f) Weakness or tingling in arms or legs
(g) Severe or worsening headache
(h )Unsteady on feet
(i) One pupil larger or smaller than the other
(j) Changes in hearing, taste or vision
(k) Repeated episodes of blacking out or passing out
Red Flags
Conduct _____ examination as close to time of injury as possible
MACE 2
Aggressive headache or pain management mild TBI
1) first 48 hours
2) after 48 hours
3) avoid what?
1) Use acetaminophen every 6 hours, for 48 hours,
2) after 48 hours, may use Naproxen as needed.
3) Avoid Tramadol, Fioricet, and Narcotics
What is the progression through stages of mild TBI management?
if symptom free
1) 24h rest
2) stage 2 5 days
3) stage 3 - 5 24h
If symptom free at rest, conduct what?
exertional testing
What is exertional testing?
-Exert to 65-85% of target heart rate (THR=220-age)
-for approximately two minutes
-Assess for symptoms
-If symptoms/red flags exist with exertional testing, stop testing, and consult with provider
If symptom free during exertional testing and this is their first concussion in the past 12 months then _______
return to duty
If symptom free during exertional testing and this is their second concussion in the past 12 months then…….
stay at stage 2 light routine activity for the next 5 days and perform NSI screening questionnaire daily
What stage?
light routine activity
a) You may wear a uniform and boots
b) May perform these activities no longer than 30 minutes – walk, stretch, ride a stationary bike at slow pace with low resistance,
c) DO NOT: Drink alcohol, play video games, do resistance training or repetitive lifting, do sit-ups, push-ups, or pull-ups, go to crowded areas where you may be bumped into.
Stage 2
What stage?
light occupation-oriented activity
a) May perform the following activities for no longer than 60 minutes: lift and carry objects less than 20 lbs take a brisk walk, ride in care and look around, use an elliptical machine or stair climber, perform light military tasks such as cleaning equipment
b) May perform these activities no longer than 30 minutes: shop for one item at the store, talk to someone as you walk, gently increase your exposure to light and noise, perform a maintenance check on a vehicle
Stage 3
If 3 or more documented concussions and/or TBI in the past 12 months then…..
Stage 1 rest and refer to Neurology for a comprehensive work-up with imaging and assessment.
What stage?
a) Resume normal routine and exercise, participate in normal military, training and social activities, use night vision goggles, take part in simulations, or be exposed to bright light, start driving again, do heavy job-related tasks, such as digging, communicate by signals during patrol duty or use radio communication
b) DO NOT: drink alcohol, participate in combative or contact sports, go outside the wire in a combat zone
Stage 5 Intensive activity
What stage?
a) You may wear personal protective equipment
b) You may perform the following activities for no longer than 90 minutes: take a brisk walk, do light resistance training, participate in non-contact sports, perform moderate job-related tasks, climb, crawl, or jog
c)You may perform these activities for no longer than 40 minutes: play video games, foosball, putting and ping-pong, play strategy games such as chess or Sudoku, shop for groceries, perform target practice, drive in a simulator
d) DO NOT: Drink alcohol, participate in combative or contact sports, drive
Stage 4 Moderate activity
